Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM)

Abstract

Introduction Peroral endoscopic myotomy (POEM) is a minimally invasive treatment for achalasia. Considerable evidence demonstrates a high incidence of gastroesophageal reflux disease (GERD) after POEM. The endoluminal functional lumen imaging probe (FLIP) uses impedance planimetry to obtain objective measurements of the gastroesophageal junction. This study aims to determine whether FLIP measurements collected at the time of POEM are associated with the development of reflux esophagitis postoperatively. Methods Patients who underwent POEM between 2012 and 2019 who subsequently had esophagogastroduodenoscopy (EGD) were included. Intraoperative FLIP measurements before and after myotomy, clinical data from EGD, and reflux specific quality of life questionnaires were collected. Comparisons between groups were made using the Wilcoxon rank-sum and Fisher's exact tests. Receiver operating characteristic (ROC) curves were used to determine optimal cutoffs of measurements to classify patients into those with high risk of postoperative esophagitis and those with lower risk. Results A total of 43 patients were included. Of those, 25 (58.1%) were found to have esophagitis on postoperative EGD: four patients (16%) with LA Grade A, five (20%) with LA Grade B, 11 (44%) with LA Grade C and two (8%) with LA grade D esophagitis. Patients with a final distensibility index ≥ 2.7 and a final cross-sectional area ≥ 83 were significantly more likely to develop esophagitis on postoperative EGD (p = 0.016 and p = 0.008, respectively). Gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) scores were not significantly different in patients who developed esophagitis and those who did not. Conclusion Reflux affects some patients after POEM. We show that FLIP measurements collected during POEM may help predict which patients are more likely to develop reflux esophagitis postoperatively. Subjective symptoms on quality of life questionnaires are not reliable in determining which patients are at risk for esophagitis.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

“…3 FLIP has been shown to predict treatment outcomes and have a role in tailoring foregut interventions such as per-oral endoscopic myotomy (POEM) or laparoscopic Heller myotomy (LHM). 15,16 In a study of 143 patients undergoing POEM, intraoperative use of FLIP during POEM resulted in additional real-time myotomy in 65% of cases and improved clinical outcomes compared with scenarios when intraoperative FLIP was not used. 17 Studies have also identified that FLIP performs superiorly to HRM in evaluation of bolus emptying against the gold standard of barium esophagram.…”

Post‐per‐oral endoscopic myotomy heartburn: It’s not always reflux: Expert review

“…4,[14][15][16][17] Importantly, the intraprocedure EndoFLIP measurement showing a higher distensibility index (≥2.7) and higher crosssectional area (≥83) are more likely to develop in post-POEM reflux esophagitis. 49 Use of an intraprocedure EndoFLIP can be used to guide the need for endoscopic fundoplication during the index POEM procedure. 50 As less than half of patients after POEM have symptomatic and objective evidence of GERD and most are managed by PPI only, there is concern regarding the combination of POEM and transoral incisionless fundoplication in every patient.…”

EndoFLIP: una nueva tecnología

“…Es importante definir cuál es el tipo de trastorno del esfínter esofágico inferior, ya sea acalasia u obstrucción al tracto de salida de la unión esofagogástrica (OTSUEG); se debe disminución de la presión del esfínter esofágico inferior medidos en la MAR (21,28,29); además, el trabajo de Campagna y colaboradores demostró que el UGE-ID no se afecta durante la anestesia general (30). De esta forma, la EndoFLIP permite establecer durante el procedimiento, si se requiere, una mayor dilatación o longitud de la miotomía hasta lograr un incremento del UGE-ID; de modo que se logra una mejor respuesta al tratamiento y disminuye el riesgo de reflujo gastroesofágico (31,32).…”